=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992906747
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID WILLIAM HAGEDORN PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2007
-----------------------------------------------------
Last Update Date | 05/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 BREWSTER BLVD NAVAL HOSPITAL - FAMILY MEDICINE
-----------------------------------------------------
City | CAMP LEJEUNE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-450-8805
-----------------------------------------------------
Fax | 910-353-1763
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 VALENCIA DRIVE SUITE 109
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28546-7807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-353-1760
-----------------------------------------------------
Fax | 910-353-1763
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1117
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY00003898
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 32594
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 3745
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------